Surgical Treatment Of Brain Metastases Research Articles

Factors associated with preoperative and postoperative seizures in patients undergoing resection of brain metastases.

Epileptic seizures are a common and potentially devastating complication of metastatic brain tumors. Although tumor-related seizures have been described in previous case series, most studies have focused on primary brain tumors and have not differentiated between different types of cerebral metastases. The authors analyzed a large surgical cohort of patients with brain metastases to examine risk factors associated with preoperative and postoperative seizures and to better understand the seizure risk factors of metastatic brain tumors. Patients who underwent resection of a brain metastasis at the University of California, San Francisco (UCSF), were retrospectively reviewed. Patients included in the study were ≥ 18 years of age, required resection of a brain metastasis, and were treated at UCSF. Primary cancers included melanoma, non-small cell lung adenocarcinoma, breast adenocarcinoma, colorectal adenocarcinoma, esophageal adenocarcinoma, gastric adenocarcinoma, renal cell carcinoma, urothelial carcinoma, ovarian carcinoma, cervical squamous cell carcinoma, and endometrial adenocarcinoma. Patients were evaluated for primary cancer type and seizure occurrence, as well as need for use of antiepileptic drugs preoperatively, at time of discharge, and at 6 months postoperatively. Additionally, Engel classification scores were assigned to those patients who initially presented with seizures preoperatively. Univariate and multivariate regression analyses were used to assess the association of tumor type with preoperative seizures. Data were retrospectively analyzed for 348 consecutive patients who underwent surgical treatment of brain metastases between 1998 and 2019. The cohort had a mean age of 60 years at the time of surgery and was 59% female. The mean and median follow-up durations after the date of surgery for the cohort were 22 months and 10.8 months, respectively. In univariate analysis, frontal lobe location (p = 0.05), melanoma (p = 0.02), KRAS mutation in lung carcinoma (p = 0.04), intratumoral hemorrhage (p = 0.04), and prior radiotherapy (p = 0.04) were associated with seizure presentation. Postoperative checkpoint inhibitor use (p = 0.002), prior radiotherapy (p = 0.05), older age (p = 0.002), distant CNS progression (p = 0.004), and parietal lobe tumor location (p = 0.002) were associated with seizures at 6 months postoperatively. The final multivariate model confirmed the independent effects of tumor location in the frontal lobe and presence of intratumoral hemorrhage as predictors of preoperative seizures, and checkpoint inhibitor use and parietal lobe location were identified as significant predictors of seizures at 6 months postoperatively. Within this surgical cohort of patients with brain metastases, seizures were seen in almost a quarter of patients preoperatively. Frontal lobe metastases and hemorrhagic tumors were associated with higher risk of preoperative seizures, whereas checkpoint inhibitor use and parietal lobe tumors appeared to be associated with seizures at 6 months postoperatively. Future research should focus on the effect of metastatic lesion-targeting therapeutic interventions on seizure control in these patients.

P08.04.B The Clinical Frailty Scale is superior to the Karnofsky Performance Status as predictor of overall survival in patients with surgical treatment of brain metastases

Abstract Background The Clinical Frailty Scale (CFS) evaluates patients’ level of frailty on a scale from 1 (very fit) to 9 (terminally ill) and is commonly used in geriatric medicine, intensive care and orthopaedics but not in patients harboring neuro-oncological diseases. Our study was conducted to reveal if the usage of CFS generates more reliable prediction of overall survival in patients after brain metastases resection rather than Karnofsky Performance Status (KPS). Material and Methods All patients which were operated for brain metastatic disease at our department from 2005-2019 were included. CFS and KPS were retrospectively assessed for the timepoints pre- and postoperatively as well during follow-up 3-6 months after resection. Results 205 patients with mean follow-up of 22.8 months (CI95% 18.4-27.1) were evaluated. Mean estimated OS was 32.1 months (CI95% 25.0-39.1). CFS showed a median of 3 points (IqR 2-4) at all 3 assessment-points which means patients were “managing well”. Median KPS was 80 preoperative (IqR 80-90) and 90 (IqR 80-100) postoperative as well as on follow-up after 3-6 months. CFS strongly correlated with KPS: preoperatively (r=-0.92; p< 0.001), postoperatively (r=-0.85; p<0.001) and at follow-up (r=-0.93; p<0.001). In the same time, CFS pre- and postoperatively showed only weak correlation with CFS at follow-up after 3-6 months (r=0.30, p<0.001; and r=0.37, p<0.001, correspondingly). In multivariate integrated Cox regression model, the CFS predicted the expected reduction of OS superior to KPS at all 3 assessment-points. One point increase of preoperative CFS represented 30% additional hazard to decease (HR=1.30, CI95% 1.15-1.46; p<0.001), correspondingly postoperative CFS provides 39% (HR=1.39, CI95% 1.25-1.54; p<0.001) and at follow-up 42% of hazard (HR= 1.42, CI95% 1.27-1.59; p<0.001). In case of KPS, decrease of 10 points resulted in additional hazards to decease of 26% (HR=0.974/point, CI95% 0.962-0.987; p<0.001) postoperatively 14% (HR=0.986/point, CI95% 0.978-0.993; p<0.001) and 31% (HR=0.969/point, CI95% 0.959-0.978; p<0.001) at follow-up. Conclusion CFS is a feasible and reliable performance scoring in patients undergoing brain metastasis resection, that provides better OS prediction as compared to KPS. Whereas, CFS at follow-up after 3-6 months specifies the expected OS most accurately. Due to weak correlation between CFS preoperatively vs. postoperatively and in 3-6 months, initial frailty does not predict the patients’ postoperative frailty score.

Surgical treatment of solitare brain metastases

Background. Brain metastasis occurs in 10–30 % of patients with different malignances. Despite of successes, achieved in the treatment of extracranial malignances in last decade, tendency to increase of the survival and duration of the disease-free period in patients with brain metastasis is absent. Several treatment modalities: chemotherapy, radiation, immune and target therapy, stereotactic radiosurgery, different types of surgical procedures, however, an optimal combination of these methods remain unclear.The aim of the study: to summarize experience of complex treatment of patients with brain metastases in hospital with opportunity of both surgical removal, chemo- and radiotherapy and review literature on the topic.Materials and methods. The retrospective analysis of medical data of patients with brain metastases performed with assessment of most frequent sources of metastases, there value, localization, median survival duration from metastasis revealing due to different types of therapy, main period of recurrences and hospital state duration, early and late complications. Inclusion criteria were: patients with surgical treatment of brain metastases, availability of medical data. Exclusion criteria were: multiple brain metastases, contraindications for surgical treatment, sensitive to chemo- and radiation therapy malignances (leukoses, lymphoma, germinative tumors etc.). The assessment of degree of metastasis resection was made by postop CT and MRI with intravenous enhancement or by operation records. Intraoperative florescence was used for evaluation of tumor borders. In case of localization of metastasis in sensory or motor zones intraoperative electrophysiological monitoring acquired. Few operations for metastasis localized in speech zones were made with «asleep–awake–asleep» method. Follow-up assessed by questioning of patients and their relatives. Statistical analyzes performed in IBM SPSS Statistics 23.Results. 52 patients meet criteria and were included to the study. Male to female ratio was 1 : 1, main age – 60 years. The most common sources of brain metastases were (in decreasing order) melanoma, lung cancer, kidney cancer, breast cancer, rectal cancer, prostate cancer, ovarian cancer and uterus cancer. Two patients had 2 brain metastases at the time of assessment, other 50 – single. Most common localizations of brain metastases (in decreasing order) were: parietal lobe, frontal lobe, cerebellum hemispheres, occipital lobe, temporal lobe, ventricular system and brain meninges. In 46 % of cases metastases involves significant functional areas of brain. Median value of metastasis was 11 cm3; midline dislocation appeared in 65,4 % of cases; 6 patients have hemorrhage in the tumor, 2 – seizures, 2 – occlusive hydrocephalus. Main Karnofsky performance index – 73,8. Total resection performed in 84,6, subtotal resection – in 7,7 % of cases gross. Intraoperative fluorescence used in 73 %. In 10 cases metastasis localized in motor and sensory zones, all these cases were treat with intraoperative neurophysiological monitoring. Postoperative hemiparesis noticed in 1 patient; 3 surgeries performed with awake; no aphasias mentioned. Follow-up was assessed in 44 patients, 20 of them were dead at the time of the study. An assessment of dependence of overall survival median on primary tumor morphology performed. Prognostic factors of brain metastases: its morphology and value, extent of resection, Karnofsky status and early complications.Conclusions. Most patients with brain metastasis are in satisfactory condition. Most frequent tumors which form brain metastasis: melanoma and lung cancer, they are characterized by poorer prognosis. Most metastasis are supratentorial, intracranial hypertension is obvious. Metastasis localization, time from its evaluation to surgery, significant functional areas involvement and primary tumor resection aren’t fluent on survival.

The Clinical Frailty Scale as useful tool in patients with brain metastases

PurposeThe Clinical Frailty Scale (CFS) evaluates patients’ level of frailty on a scale from 1 to 9 and is commonly used in geriatric medicine, intensive care and orthopedics. The aim of our study was to reveal whether the CFS allows a reliable prediction of overall survival (OS) in patients after surgical treatment of brain metastases (BM) compared to the Karnofsky Performance Score (KPS).MethodsPatients operated for BM were included. CFS and KPS were retrospectively assessed pre- and postoperatively and at follow-up 3–6 months after resection.Results205 patients with a follow-up of 22.8 months (95% CI 18.4–27.1) were evaluated. CFS showed a median of 3 (“managing well”; IqR 2–4) at all 3 assessment-points. Median KPS was 80 preoperatively (IqR 80–90) and 90 postoperatively (IqR 80–100) as well as at follow-up after 3–6 months. CFS correlated with KPS both preoperatively (r = − 0.92; p < 0.001), postoperatively (r = − 0.85; p < 0.001) and at follow-up (r = − 0.93; p < 0.001).The CFS predicted the expected reduction of OS more reliably than the KPS at all 3 assessments. A one-point increase (worsening) of the preoperative CFS translated into a 30% additional hazard to decease (HR 1.30, 95% CI 1.15–1.46; p < 0.001). A one-point increase in postoperative and at follow-up CFS represents a 39% (HR 1.39, 95% CI 1.25–1.54; p < 0.001) and of 42% risk (HR 1.42, 95% CI 1.27–1.59; p < 0.001).ConclusionThe CFS is a feasible, simple and reliable scoring system in patients undergoing resection of brain metastasis. The CFS 3–6 months after surgery specifies the expected OS more accurately than the KPS.

Benchmarking Safety Indicators of Surgical Treatment of Brain Metastases Combined with Intraoperative Radiotherapy: Results of Prospective Observational Study with Comparative Matched-Pair Analysis.

Simple SummaryPatients with brain metastasis (BM) are at advanced stages of metastatic cancer, and surgical resection is often required in order to avoid severe neurologic deficits. After surgery, patients are usually committed to postoperative radiotherapy. In recent years, intraoperative radiotherapy (IORT) has been proposed as an alternative to conventional postsurgical radiation approaches. This possibility has several advantages, e.g., as IORT is administered only once during the surgical procedure, patients do not have to attend several radiotherapy sessions afterward. However, the application of radiation therapy directly into the open brain during surgery might be accompanied by severe perioperative complications and, therefore, might negatively impact the overall benefit. In the present study, we show that patients who underwent surgery for BM combined with IORT do not suffer from elevated levels of perioperative complications compared to patients without IORT. Therefore, IORT constitutes a safe treatment strategy for cancer patients with BM.Intraoperative radiotherapy (IORT) of the operative cavity for surgically treated brain metastasis (BM) has gained increasing prominence with respect to improved local tumor control. However, IORT immediately performed at the time of surgery might be associated with increased levels of perioperative adverse events (PAEs). In the present study, we performed safety metric profiling in patients who had undergone surgery for BM with and without IORT in order to comparatively analyze feasibility of IORT as an adjuvant radiation approach. Between November 2020 and October 2021, 35 patients were surgically treated for BM with IORT at our neuro-oncological center. Perioperative complication profiles were collected in a prospective observational cohort study by means of patient safety indicators (PSIs), hospital-acquired conditions (HACs), and specific cranial-surgery-related complications (CSCs) as high-standard quality metric tools and compared to those of an institutional cohort of 388 patients with BM resection without IORT in a balanced comparative matched-pair analysis. Overall, 4 out of 35 patients (11%) with IORT in the course BM resection suffered from PAEs, accounting for 3 PSIs (9%) and 1 HAC (3%). Balanced matched-pair analysis did not reveal significant differences in the perioperative complication profiles between the cohorts of patients with and without IORT (p = 0.44). Thirty-day mortality rates were 6% for patients with IORT versus 8% for patients without IORT (p = 0.73). The present study demonstrates that IORT constitutes a safe and clinically feasible adjuvant treatment modality in patients undergoing surgical resection of BM.

The Clinical Frailty Scale is superior to the Karnofsky Performance Status as predictor of overall survival in patients with surgical treatment of brain metastases

The Clinical Frailty Scale is superior to the Karnofsky Performance Status as predictor of overall survival in patients with surgical treatment of brain metastases

Двухэтапная стажированная стереотаксическая радиохирургия на Гамма-ноже в лечении метастазов в головной мозг

The aim of this study was to assess the efficacy and safety of two-stage stereotactic radiosurgery using Gamma Knife for treatment of brain metastases. Staging was applied to patients with large metastases, as well as to metastases located near critical structures. In a group of 31 patients, treatment was carried out in 2 stages with 2-4 weeks interval. The mean tumor volume at the time of the first radiosurgery was 10.4 cm3 (0.52 to 19.07; 95% CI: 8.2-12 cm3). The marginal dose at the first and second stages of radiosurgery ranged from 12 to 14.4 Gy, respectively. Median fol-low-up time was 169 days. Overall survival rate, local control, the incidence of complications, as well as changes in functional status were evaluated. Decrease in volume of tumors between irra-diation sessions averaged 36.2%. Overall survival at 3, 6, 12 months was 70, 57.7 and 52%, re-spectively. Local control after 3, 6, 12 months was 92, 87 and 66%, respectively. Radionecrosis was found out in 2 patients. Increase of Carnovsky index in study group after treatment was by an average of 10 points (p=0.007). Thus, two-stage trained stereotactic radiosurgery can be a safe and effective alternative to surgical treatment of brain metastases without worsening the neuro-logical status of patients.

The Surgical Management of Brain Metastases in Non-Small Cell Lung Cancer (NSCLC): Identification of the Early Laboratory and Clinical Determinants of Survival.

Background: Brain metastases (BM) indicate advanced states of cancer disease and cranial surgery represents a common treatment modality. In the present study, we aimed to identify the risk factors for a reduced survival in patients receiving a surgical treatment of BM derived from non-small cell lung cancer (NSCLC). Methods: A total of 154 patients with NSCLC that had been surgically treated for BM at the authors’ institution between 2013 and 2018 were included for a further analysis. A multivariate analysis was performed to identify the predictors of a poor overall survival (OS). Results: The median overall survival (mOS) was 11 months (95% CI 8.2–13.8). An age > 65 years, the infratentorial location of BM, elevated preoperative C-reactive protein levels, a perioperative red blood cell transfusion, postoperative prolonged mechanical ventilation (>48 h) and the occurrence of postoperative adverse events were identified as independent factors of a poor OS. Conclusions: The present study identified several predictors for a worsened OS in patients that underwent surgery for BM of NSCLC. These findings might guide a better risk/benefit assessment in the course of metastatic NSCLC therapy and might help to more sufficiently cope with the challenges of cancer therapy in these advanced stages of disease.

The Impact of Prolonged Mechanical Ventilation on Overall Survival in Patients With Surgically Treated Brain Metastases

ObjectiveSurgical resection represents a common treatment modality in patients with brain metastasis (BM). Postoperative prolonged mechanical ventilation (PMV) might have an enormous impact on the overall survival (OS) of these patients suffering from advanced cancer disease. We therefore have analyzed our institutional database with regard to a potential impact of PMV on OS of patients who had undergone surgery for brain metastases.Methods360 patients with surgically treated brain metastases were included. The definition of PMV consisted of postoperative mechanical ventilation lasting for more than 48 hours. Analysis of survival incorporating established prognostic factors such as age, location of BM, and preoperative physical status was performed.Results14 of 360 patients with BM (4%) suffered from postoperative PMV after surgical treatment of BM. Patients with PMV presented in a significantly more impaired neurological condition preoperatively than patients without (p<0.0001). Multivariate analysis determined PMV to be a significant prognostic factor for OS after surgical treatment in patients with BM, independent of other predictive factors (p<0.0001).ConclusionsThe present study demonstrates postoperative PMV as significantly related to poor OS in patients with surgically treated BM. Postoperative PMV is a so far underestimated prognostic predictor, but might be utilized for optimized patient management early in the postoperative phase. For this purpose, the results of the present study should encourage the initiation of further scientific efforts.

Surgical treatment of brain metastases

Surgical treatment of brain metastases

Metastatic melanoma: Surgical treatment of brain metastases – Analysis of 110 patients

New Zealand has one of the highest rates of melanoma in the world. In up to 10% of cases, the disease is metastatic at diagnosis. Cerebral metastatic involvement carries a particularly poor prognosis. 110 patients were included in the analysis. A retrospective consecutive series of patients treated surgically at Auckland City Hospital were studied, with parameters of demographics, tumour characteristics, surgery, pathology, systemic therapy and survival analysed. Mean age was 59.9 years (range 22–81 years). Median survival from date of surgery was 8.1 months (95% CI 6.9–9.4 months). Of the 58 patients tested for BRAF mutation, 28 were positive, similar to previously published data. This conferred a better prognosis with median overall survival of 12.3 months (95% CI 7.2–17.3 months) compared to 7.8 months (95% CI 5.6–10 months) for those who were negative (p < 0.05). Survival correlated positively with extent of surgical resection. Both BRAF positive status and targeted and/or immunotherapy were significant predictors of improved survival. In this cohort, radiation therapy did not show a statistically significant improvement in overall survival.Survival from resection of cerebral metastases from melanoma is improving. Survival benefit is conferred by BRAF mutation, solitary metastasis and gross total resection of lesion.

Surgical Treatment of Brain Metastasis of Axillary Apocrine Cell Carcinoma - Case Report

Surgical Treatment of Brain Metastasis of Axillary Apocrine Cell Carcinoma - Case Report

The Value of Preoperative Planning Based on Navigated Transcranical Magnetic Stimulation for Surgical Treatment of Brain Metastases Located in the Perisylvian Area

Brain metastases are the most common neoplasms in adults. When brain metastases are located in eloquent areas, their treatment still seems controversial and not clearly defined. It is therefore essential to provide correct preoperative planning to better define extension and characterization of brain metastasis. We retrospectively looked for the tumor database of our institution, patients with single brain metastasis, located in the sylvian area, who underwent resection with the support of intraoperative neurophysiologic monitoring between 2008 and2018. We retrieved data for 30 adults, each with a single brain metastasis that was located in the sylvian area, including the insula and the lower portion of the motor cortex. Neuronavigation and the intraoperative visualization of the navigated transcranial magnetic stimulation-based reconstruction of functional networks were used to delineate the ideal trajectory toward the lesion. The Karnofsky Performance Status significantly improved in the postoperative period. The correct planning of brain metastasis allows more secure removal of the neoplastic lesion, avoiding and/or reducing the appearance of neurologic deficits. Navigated transcranial magnetic stimulation represents a new method that can promote a more complete and safer resection of the metastatic lesion in eloquent areas. An optimal surgical result, in the absence of postoperative neurologic deficits, allows the patient to undertake adjuvant therapy able to prolong survival.

Outcome of Cerebral Metastasectomy in Select Cases of Brain Metastases from Breast Cancer in Ibadan, Nigeria

Brain metastasis (BM) from breast cancer is increasingly encountered clinically because of the continuing success in the oncological control of the primary disease. Data-driven reports on the surgical treatment of BM from breast cancer are sparse in sub-Saharan Africa. This is a prospective cohort study of the outcome of surgical excision of BM from breast cancer in an academic surgical practice in Ibadan, Nigeria. A total of 12 consecutive cerebral metastasectomies, all in females with primary breast cancer, were recorded over the study period. The median age (range) at breast cancer diagnosis was 41 (27-72) years, and the time interval from primary disease to BM was 19 (12-29) months. The BM was the first site of systemic disease progression in all, and was heralded by headache, seizures, and hemiparesis in more than two-thirds of the patients. The brain lesions were multiple in a quarter: >4 cm large in 42% and were located supratentorial in >80%. They all achieved good recovery and in-hospital outcome after surgical lesionectomy-infra- and supratentorial craniotomies-but only two-thirds could access postsurgical adjuvant whole brain radiation therapy. Median survival after cerebral metastasectomy was 18 (11-55) months, and more than a quarter were alive for ≥3years. These survival statistics were significantly better than those of a contemporary cohort of our patients with breast cancer who also had BMs that were not surgically treated for various clinical and logistic limitations. Surgical resection is feasible for BM from breast cancer even in low-resource clinical practice. It has a salutary effect on the patients' quality of life.

Management of Intracranial Metastatic Disease With Laser Interstitial Thermal Therapy.

Treatment approaches for metastatic brain tumors continue to evolve, with increasing recent emphasis on focal therapies whenever possible. MRI-guided Laser Interstitial Thermal Therapy (LITT) is a minimally invasive surgical option that has broadened the capability of the neurosurgeon in treating difficult-to-treat intracranial lesions. This technology uses image-guided delivery of laser to the target lesion to generate heat and thereby ablate pathological tissue and has expanded the neurosurgical armamentarium for surgical treatment of brain metastases. In this study, we describe the indications for LITT in the management of intracranial metastatic disease and report our institutional experience with LITT.

Functional approach using intraoperative brain mapping and neurophysiological monitoring for the surgical treatment of brain metastases in the central region.

OBJECTIVE Brain metastases are the most frequent intracranial malignant tumor in adults. Surgical intervention for metastases in eloquent areas remains controversial and challenging. Even when metastases are not infiltrating intra-parenchymal tumors, eloquent areas can be affected. Therefore, this study aimed to describe the role of a functional guided approach for the resection of brain metastases in the central region. METHODS Thirty-three patients (19 men and 14 women) with perirolandic metastases who were treated at the authors' institution were reviewed. All participants underwent resection using a functional guided approach, which consisted of using intraoperative brain mapping and/or neurophysiological monitoring to aid in the resection, depending on the functionality of the brain parenchyma surrounding each metastasis. Motor and sensory functions were monitored in all patients, and supplementary motor and language area functions were assessed in 5 and 4 patients, respectively. Clinical data were analyzed at presentation, discharge, and the 6-month follow-up. RESULTS The most frequent presenting symptom was seizure, followed by paresis. Gross-total removal of the metastasis was achieved in 31 patients (93.9%). There were 6 deaths during the follow-up period. After the removal of the metastasis, 6 patients (18.2%) presented with transient neurological worsening, of whom 4 had worsening of motor function impairment and 2 had acquired new sensory disturbances. Total recovery was achieved before the 3rd month of follow-up in all cases. Excluding those patients who died due to the progression of systemic illness, 88.9% of patients had a Karnofsky Performance Scale score greater than 80% at the 6-month follow-up. The mean survival time was 24.4 months after surgery. CONCLUSIONS The implementation of intraoperative electrical brain stimulation techniques in the resection of central region metastases may improve surgical planning and resection and may spare eloquent areas. This approach also facilitates maximal resection in these and other critical functional areas, thereby helping to avoid new postoperative neurological deficits. Avoiding permanent neurological deficits is critical for a good quality of life, especially in patients with a life expectancy of over a year.

Efficacy of surgical treatment for brain metastasis in patients with non-small cell lung cancer.

PurposePatients with non-small cell lung cancer (NSCLC) and simultaneously having brain metastases at the initial diagnosis, presenting symptoms related brain metastasis, survived shorter duration and showed poor quality of life. We analyzed our experiences on surgical treatment of brain metastasis in patients with NSCLC.Materials and MethodsWe performed a single-center, retrospective review of 36 patients with NSCLC and synchronous brain metastases between April 2006 and December 2011. Patients were categorized according to the presence of neurological symptoms and having a brain surgery. As a result, 14 patients did not show neurological symptoms and 22 patients presented neurological symptoms. Symptomatic 22 patients were divided into two groups according to undergoing brain surgery (neurosurgery group; n=11, non-neurosurgery group; n=11). We analyzed overall surgery (OS), intracranial progression-free survival (PFS), and quality of life.ResultsSurvival analysis showed there was no difference between patients with neurosurgery (OS, 12.1 months) and non-neurosurgery (OS, 10.2 months; p=0.550). Likewise for intracranial PFS, there was no significant difference between patients with neurosurgery (PFS, 6.3 months) and non-neurosurgery (PFS, 5.3 months; p=0.666). Reliable neurological one month follow up by the Medical Research Council neurological function evaluation scale were performed in symptomatic 22 patients. The scale improved in eight (73%) patients in the neurosurgery group, but only in three (27%) patients in the non-neurosurgery group (p=0.0495).ConclusionPatients with NSCLC and synchronous brain metastases, presenting neurological symptoms showed no survival benefit from neurosurgical resection, although quality of life was improved due to early control of neurological symptoms.

Management of brain metastases: the indispensable role of surgery

Brain metastases are the most common neurological complication of systemic cancer and carry a very poor prognosis. The management of patients with brain metastases has become more important recently because of the increased incidence of these tumors and the prolonged patient survival times that have accompanied increased control of systemic cancer. In this article, we review the current perspectives on surgical treatment of brain metastases in terms of patient selection criteria, intraoperative adjuncts, whole-brain radiation therapy (WBRT) as a postoperative adjuvant, reoperation for tumor recurrence, and resection of multiple and single metastases. Achieving the best outcome in treatment of brain metastasis requires the judicious and complementary use of surgical resection along with modalities such as whole-brain radiation therapy and stereotactic radiosurgery.

Current Treatment Approaches to Surgery for Brain Metastases

The role for surgical treatment of brain metastases continues to evolve. Data have demonstrated survival and quality-of-life benefits for surgical treatment of appropriate lesions in selected patients. With improvements in surgical technique, along with therapeutic improvements in the management of systemic cancers, more patients are now eligible for surgical resection. Selection of patients for surgical treatment depends on performance status, size, location, and number of brain lesions, as well as the status of systemic disease. Although surgery has traditionally been performed for patients with a single brain metastasis, an increasing number of patients with multiple brain metastases may also be treated surgically. Surgical techniques, such as image guidance, intraoperative ultrasound, functional neuronavigation, cortical mapping, and awake craniotomies, have expanded the scope of lesions that can be removed safely to optimize outcomes. Seizures, peritumoral edema, and venous thromboembolic disease all contribute significantly to surgical morbidity and mortality and thus require aggressive treatment around the time of the surgical procedure to improve the quality of life and maximize survival time.

Surgical treatment of brain metastasis

Treatment modalities for brain metastasis or metastatic brain tumor include surgery, conventional irradiation, stereotactic radiosurgery (SRS), chemotherapy, and supportive care with corticosteroid. In most cases, these treatments are used in combination. For a single metastasis, surgery followed by whole-brain radiation therapy (WBRT) has been the standard treatment. SRS has become increasingly popular and challenges the standard procedure, but there are still insufficient data for the outcomes of combinations including SRS. For the treatment of multiple metastases, WBRT is the standard procedure. For tumors larger than 3 cm, and in life-threatening situations such as a large metastasis to the cerebellum, surgery is the only feasible approach. Histological examination is sometimes useful for characterizing metastatic tumors from unknown primary sites. Thus, although brain metastasis invariably indicates a stage 4 cancer, some patients can benefit from surgery.